Third Test i had to fucking redo because they changed units Flashcards
In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the patient states:
a. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
b. “Insulin dosage will likely need to be increased during the second and third trimesters.”
c. “Episodes of hypoglycemia are more likely to occur during the first 3 months.”
d. “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding.”
ANS: A
Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. “Insulin dosage will likely need to be increased during the second and third trimesters,” “Episodes of hypoglycemia are more likely to occur during the first 3 months,” and “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding” are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy.
Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with:
a. frequent episodes of maternal hypoglycemia.
b. congenital anomalies in the fetus.
c. polyhydramnios.
d. hyperemesis gravidarum.
ANS: B
Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contributes to hypoglycemia.
In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:
a. mother’s age.
b. number of years since diabetes was diagnosed.
c. amount of insulin required prenatally.
d. degree of glycemic control during pregnancy.
ANS: D
Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes
Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:
a. macrosomia.
b. congenital anomalies of the central nervous system.
c. preterm birth.
d. low birth weight.
ANS: A
Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.
A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 lbs less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time?
a. Deficient fluid volume
b. Imbalanced nutrition: less than body requirements
c. Imbalanced nutrition: more than body requirements
d. Disturbed sleep pattern
ANS: B
This patient’s clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This patient reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the patient reports nervousness based on the patient’s other clinical symptoms the most appropriate nursing diagnosis would be Imbalanced nutrition: less than body requirements.
Maternal phenylketonuria (PKU) is an important health concern during pregnancy because:
a. it is a recognized cause of preterm labor.
b. the fetus may develop neurologic problems.
c. a pregnant woman is more likely to die without dietary control.
d. women with PKU are usually retarded and should not reproduce.
ANS: B
Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of uncertain etiology, or who have given birth to microcephalic infants.
In terms of the incidence and classification of diabetes, maternity nurses should know that:
a. type 1 diabetes is most common.
b. type 2 diabetes often goes undiagnosed.
c. gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth.
d. type 1 diabetes may become type 2 during pregnancy.
ANS: B
Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between type 1 and 2 diabetes.
Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that:
a. insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own.
b. women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar.
c. during the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.
d. maternal insulin requirements steadily decline during pregnancy.
ANS: C
Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the 10th week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.
With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that:
a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
b. Hydramnios occurs approximately twice as often in diabetic pregnancies.
c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies.
d. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.
ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.
The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc:
a. is now done for all pregnant women, not just those with or likely to have diabetes.
b. is a snapshot of glucose control at the moment.
c. would be considered evidence of good diabetes control with a result of 5% to 6%.
d. is done on the patient’s urine, not her blood.
ANS: C
A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood.
A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)?
a. 75 mg/dL before lunch. This is low; better eat now.
b. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time.
c. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin.
d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
ANS: D
60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL.
A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding?
a. Hyperthyroidism
b. Phenylketonuria (PKU)
c. Hypothyroidism
d. Thyroid storm
ANS: B
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism
When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include:
a. a regular heart rate and hypertension.
b. an increased urinary output, tachycardia, and dry cough.
c. shortness of breath, bradycardia, and hypertension.
d. dyspnea; crackles; and an irregular, weak pulse.
ANS: D
Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nail beds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation, but increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation, but bradycardia and hypertension would not.
While providing care in an obstetric setting, the nurse should understand that after birth care of the woman with cardiac disease:
a. is the same as that for any pregnant woman.
b. includes rest, stool softeners, and monitoring of the effect of activity.
c. includes ambulating frequently, alternating with active range of motion.
d. includes limiting visits with the infant to once per day.
ANS: B
Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the after birth period is tailored to the woman’s functional capacity. The woman will be on bed rest to conserve energy and reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.
A woman with asthma is experiencing a after birth hemorrhage. Which drug would not be used to treat her bleeding because it may exacerbate her asthma?
a. Pitocin
b. Nonsteroidal anti-inflammatory drugs (NSAIDs)
c. Hemabate
d. Fentanyl
ANS: C
Prostaglandin derivatives should not be used to treat women with asthma because they may exacerbate symptoms. Pitocin would be the drug of choice to treat this woman’s bleeding because it would not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding.
The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this patient population the nurse must be cognizant that methamphetamine:
a. is similar to opiates.
b. is a stimulant with vasoconstrictive characteristics.
c. should not be discontinued during pregnancy.
d. is associated with a low rate of relapse.
ANS: B
Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are used similarly. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high.
Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to statistics, how often does cystic fibrosis occur in Caucasian live births?
a. 1 in 100
b. 1 in 1200
c. 1 in 2500
d. 1 in 3000
ANS: D
Cystic fibrosis occurs in about 1 in 3000 Caucasian live births.
Which heart condition is not a contraindication for pregnancy?
a. Peripartum cardiomyopathy
b. Eisenmenger syndrome
c. Heart transplant
d. All of these contraindicate pregnancy
ANS: C
Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation.
During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:
a. euglycemia.
b. rheumatic fever.
c. pneumonia.
d. cardiac decompensation.
ANS: D
Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not manifest with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation.
Nurses caring for antepartum women with cardiac conditions should be aware that:
a. stress on the heart is greatest in the first trimester and the last 2 weeks before labor.
b. women with Class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms.
c. women with Class III cardiac disease should have 8 to 10 hours of sleep every day and limit housework, shopping, and exercise.
d. Women with Class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.
ANS: B
Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can carry on limited normal activities with discretion, although they still need a good amount of sleep.
As related to the care of the patient with anemia, the nurse should be aware that:
a. it is the most common medical disorder of pregnancy.
b. it can trigger reflex brachycardia.
c. the most common form of anemia is caused by folate deficiency.
d. thalassemia is a european version of sickle cell anemia
ANS: A
Combined with any other complication, anemia can result in congestive heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.
The most common neurologic disorder accompanying pregnancy is:
a. eclampsia.
b. Bell’s palsy.
c. epilepsy.
d. multiple sclerosis.
ANS: C
The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic disorder accompanying pregnancy. Bell’s palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth.
With one exception, the safest pregnancy is one in which the woman is drug and alcohol free. For women addicted to opioids, ________________________ treatment is the current standard of care during pregnancy.
a. methadone maintenance
b. detoxification
c. smoking cessation
d. 4 Ps Plus
ANS: A
Methadone maintenance treatment (MMT) is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for opioid addiction treatment that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease rates of infections such as hepatitis B and C, HIV, and other sexually transmitted infections. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool designed specifically to identify pregnant women who need in-depth assessment related to substance abuse.
Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
a. Hypoglycemia
b. Hypercalcemia
c. Hypobilirubinemia
d. Hypoinsulinemia
ANS: A
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonate’s circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia.
Which factor is known to increase the risk of gestational diabetes mellitus?
a. Underweight before pregnancy
b. Maternal age younger than 25 years
c. Previous birth of large infant
d. Previous diagnosis of type 2 diabetes mellitus
ANS: C
Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
Glucose metabolism is profoundly affected during pregnancy because:
a. pancreatic function in the islets of Langerhans is affected by pregnancy.
b. the pregnant woman uses glucose at a more rapid rate than the nonpregnant woman.
c. the pregnant woman increases her dietary intake significantly.
d. placental hormones are antagonistic to insulin, thus resulting in insulin resistance.
ANS: D
Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.
To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by:
a. eating six small equal meals per day.
b. reducing carbohydrates in her diet.
c. eating her meals and snacks on a fixed schedule.
d. increasing her consumption of protein.
ANS: C
Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.
When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient:
a. eat six saltine crackers.
b. drink 8 ounces of orange juice with 2 tsp of sugar added.
c. drink 4 ounces of orange juice followed by 8 ounces of milk.
d. eat hard candy or commercial glucose wafers.
ANS: A
Crackers provide carbohydrates in the form of polysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides.
Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin:
a. increases throughout pregnancy and the after birth period.
b. decreases throughout pregnancy and the after birth period.
c. varies depending on the stage of gestation.
d. should not change because the fetus produces its own insulin.
ANS: C
Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy.
In caring for a pregnant woman with sickle cell anemia, the nurse is aware that signs and symptoms of sickle cell crisis include:
a. anemia.
b. endometritis.
c. fever and pain.
d. urinary tract infection.
ANS: C
Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Women with sickle cell trait usually are at greater risk for after birth endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis.
Congenital anomalies can occur with the use of antiepileptic drugs (AEDs), including: (Select all that apply.)
a. cleft lip.
b. congenital heart disease.
c. neural tube defects.
d. gastroschisis.
e. diaphragmatic hernia.
ANS: A, B, C
Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis and diaphragmatic hernia are not associated with the use of AEDs.
Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: (Select all that apply.)
a. atherosclerosis.
b. retinopathy.
c. IUFD.
d. nephropathy.
e. neuropathy.
ANS: A, B, D, E
These structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves. Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.
Autoimmune disorders often occur during pregnancy because a large percentage of women with an autoimmune disorder are of childbearing age. Identify all disorders that fall into the category of collagen vascular disease.
a. Multiple sclerosis
b. Systemic lupus erythematosus
c. Antiphospholipid syndrome
d. Rheumatoid arthritis
e. Myasthenia gravis
ANS: B, C, D, E
Multiple sclerosis is not an autoimmune disorder. This patchy demyelinization of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. They include those listed, as well as systemic sclerosis.
Achieving and maintaining euglycemia comprise the primary goals of medical therapy for the pregnant woman with diabetes. These goals are achieved through a combination of diet, insulin, exercise, and blood glucose monitoring. The target blood glucose levels 1 hour after a meal should be _________________.
ANS:
130 to 140 mg/dL
Target levels of blood glucose during pregnancy are lower than nonpregnant values. Accepted fasting levels are between 65 and 95 mg/dL, and 1-hour postmeal levels should be less than 130 to 140 mg/dL. Two-hour postmeal levels should be 120 mg/dL or less.
Women with hyperemesis gravidarum:
a. are a majority because 80% of all pregnant women suffer from it at some time.
b. have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance.
c. need intravenous (IV) fluid and nutrition for most of their pregnancy.
d. often inspire similar, milder symptoms in their male partners and mothers.
ANS: B
Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is seldom needed for very long. Women suffering from this condition want sympathy because some authorities believe that difficult relationships with mothers and/or partners may be the cause.
Because pregnant women may need surgery during pregnancy, nurses should be aware that:
a. the diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy.
b. rupture of the appendix is less likely in pregnant women because of the close monitoring.
c. surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.
d. when pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.
ANS: A
Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a woman to ovarian problems.
What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?
a. Bleeding time of 10 minutes
b. Presence of fibrin split products
c. Thrombocytopenia
d. Hyperfibrinogenemia
ANS B
Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.
In caring for an immediate after birth patient, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:
a. disseminated intravascular coagulation (DIC).
b. amniotic fluid embolism (AFE).
c. hemorrhage.
d. HELLP syndrome.
ANS: A
The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman’s arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the after birth patient. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.
In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?
a. Administration of blood
b. Preparation of the patient for invasive hemodynamic monitoring
c. Restriction of intravascular fluids
d. Administration of steroids
ANS: A
Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a patient with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.
A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg.
b. Weight gain of 0.5 kg during the past 2 weeks.
c. A dipstick value of 3+ for protein in her urine.
d. Pitting pedal edema at the end of the day.
ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or in diastolic pressure of 15 mm Hg. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman’s latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of:
a. eclampsia.
b. disseminated intravascular coagulation (DIC).
c. HELLP syndrome.
d. idiopathic thrombocytopenia.
ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.
A woman with preeclampsia has a seizure. The nurse’s primary duty during the seizure is to:
a. insert an oral airway.
b. suction the mouth to prevent aspiration.
c. administer oxygen by mask.
d. stay with the patient and call for help.
ANS: D
If a patient becomes eclamptic, the nurse should stay her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient’s head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient’s mouth. Oxygen would be administered after the convulsion has ended.
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The patient complains, “I’m so thirsty and warm.” The nurse:
a. calls for a stat magnesium sulfate level.
b. administers oxygen.
c. discontinues the magnesium sulfate infusion.
d. prepares to administer hydralazine.
ANS: C
The patient is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.
A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:
a. hydralazine.
b. magnesium sulfate bolus.
c. diazepam.
d. calcium gluconate.
ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically, it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The patient is not currently displaying any signs or symptoms of magnesium toxicity.
A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:
a. eclamptic seizure.
b. rupture of the uterus.
c. placenta previa.
d. placental abruption.
ANS: D
Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.
The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:
a. a sleepy, sedated affect.
b. a respiratory rate of 10 breaths/min.
c. deep tendon reflexes of 2.
d. absent ankle clonus.
ANS: B
A respiratory rate of 10 breaths/min indicates that the patient is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the patient will most likely become sedated when the infusion is initiated. Deep tendon reflexes of two and absent ankle clonus are normal findings.
The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:
a. hypertension.
b. hyperemesis gravidarum.
c. hemorrhagic complications.
d. infections.
ANS: A
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common.
Nurses should be aware that HELLP syndrome:
a. is a mild form of preeclampsia.
b. can be diagnosed by a nurse alert to its symptoms.
c. is characterized by hemolysis, elevated liver enzymes, and low platelets.
d. is associated with preterm labor but not perinatal mortality.
ANS C
The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased, and so is perinatal mortality.
Nurses should be aware that chronic hypertension:
a. is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy.
b. is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg.
c. is general hypertension plus proteinuria.
d. can occur independently of or simultaneously with gestational hypertension.
ANS: D
Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks after birth. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.
In planning care for women with preeclampsia, nurses should be aware that:
a. induction of labor is likely, as near term as possible.
b. if at home, the woman should be confined to her bed, even with mild preeclampsia.
c. a special diet low in protein and salt should be initiated.
d. vaginal birth is still an option, even in severe cases.
ANS: A
Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.
Magnesium sulfate is given to women with preeclampsia and eclampsia to:
a. improve patellar reflexes and increase respiratory efficiency.
b. shorten the duration of labor.
c. prevent and treat convulsions.
d. prevent a boggy uterus and lessen lochial flow.
ANS: C
Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy
A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?
a. Incomplete
b. Inevitable
c. Threatened
d. Septic
ANS: C
A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild to severe cramping, and cervical dilation. An inevitable abortion manifests with the same symptoms as an incomplete abortion: heavy bleeding, mild to severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix.
The perinatal nurse is giving discharge instructions to a woman after suction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be:
a. “If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available.”
b. “The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.”
c. “If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.”
d. “Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.”
ANS: B
This is an accurate statement. Beta-human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a “zero” hCG level. If the woman were to become pregnant, it could obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device is acceptable.
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:
a. bleeding.
b. intense abdominal pain.
c. uterine activity.
d. cramping.
ANS: B
Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.
Methotrexate is recommended as part of the treatment plan for which obstetric complication?
a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae
ANS: C
Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for complete hydatidiform mole, missed abortion, and abruptio placentae.
A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure?
a. Amniocentesis for fetal lung maturity
b. Ultrasound for placental location
c. Contraction stress test (CST)
d. Internal fetal monitoring
ANS B
The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.
A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of:
a. placenta previa.
b. vasa previa.
c. severe abruptio placentae.
d. disseminated intravascular coagulation (DIC).
ANS: B
Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a board-like uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors.
A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the woman’s umbilicus and recognizes this assessment finding as:
a. normal integumentary changes associated with pregnancy.
b. Turner’s sign associated with appendicitis.
c. Cullen’s sign associated with a ruptured ectopic pregnancy.
d. Chadwick’s sign associated with early pregnancy.
ANS: C
Cullen’s sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turner’s sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick’s sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.
As related to the care of the patient with miscarriage, nurses should be aware that:
a. it is a natural pregnancy loss before labor begins.
b. it occurs in fewer than 5% of all clinically recognized pregnancies.
c. it often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise.
d. if it occurs before the 12th week of pregnancy, it may manifest only as moderate discomfort and blood loss.
ANS: D
Before the sixth week the only evidence may be a heavy menstrual flow. After the 12th week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mother’s control or knowledge.
Which condition would not be classified as a bleeding disorder in late pregnancy?
a. Placenta previa
b. Abruptio placentae
c. Spontaneous abortion
d. Cord insertion
ANS: C
Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy.
In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would:
a. assess the woman’s dietary history for adequate calories and proteins.
b. instruct the woman that the bulk of calories should come from proteins.
c. instruct the woman to eat a low-fat diet and avoid fried foods.
d. instruct the woman to eat a low-cholesterol, low-salt diet.
ANS: C
Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this patient. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated.
Which maternal condition always necessitates delivery by cesarean section?
a. Partial abruptio placentae
b. Total placenta previa
c. Ectopic pregnancy
d. Eclampsia
ANS: B
In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control.
Spontaneous termination of a pregnancy is considered to be an abortion if:
a. the pregnancy is less than 20 weeks.
b. the fetus weighs less than 1000 g.
c. the products of conception are passed intact.
d. no evidence exists of intrauterine infection.
ANS: A
An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection.
An abortion in which the fetus dies but is retained within the uterus is called a(n):
a. inevitable abortion.
b. missed abortion.
c. incomplete abortion.
d. threatened abortion.
ANS: B
Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.
A placenta previa in which the placental edge just reaches the internal os is more commonly known as:
a. total.
b. partial.
c. complete.
d. marginal.
ANS: D
A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. When the patient experiences a partial placenta previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete placenta previa is termed total. The placenta completely covers the internal cervical os.
Which condition indicates concealed hemorrhage when the patient experiences an abruptio placentae?
a. Decrease in abdominal pain
b. Bradycardia
c. Hard, board-like abdomen
d. Decrease in fundal height
ANS: C
Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, board-like abdomen. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase.
The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to:
a. assess fetal heart rate (FHR) and maternal vital signs.
b. perform a venipuncture for hemoglobin and hematocrit levels.
c. place clean disposable pads to collect any drainage.
d. monitor uterine contractions.
ANS: A
Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.
A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of:
a. anxiety due to hospitalization.
b. worsening disease and impending convulsion.
c. effects of magnesium sulfate.
d. gastrointestinal upset.
ANS: B
Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication.
Which order should the nurse expect for a patient admitted with a threatened abortion?
a. Bed rest
b. Ritodrine IV
c. NPO
d. Narcotic analgesia every 3 hours, prn
ANS: A
Decreasing the woman’s activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine IV is not the first drug of choice for tocolytic medications. There is no reason for having the woman placed NPO. At times dehydration may produce contractions, so hydration is important. Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that:
a. bed rest and analgesics are the recommended treatment.
b. she will be unable to conceive in the future.
c. a D&C will be performed to remove the products of conception.
d. hemorrhage is the major concern.
ANS: D
Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture in order to prevent hemorrhaging. If the tube must be removed, the woman’s fertility will decrease; however, she will not be infertile.
D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.
Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion?
a. Chromosomal abnormalities
b. Infections
c. Endocrine imbalance
d. Immunologic factors
ANS: A
At least 50% of pregnancy losses result from chromosomal abnormalities that are incompatible with life. Maternal infection may be a cause of early miscarriage. Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss. Women who have repeated early pregnancy losses appear to have immunologic factors that play a role in spontaneous abortion incidents.
The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve:
a. corticosteroids to reduce inflammation.
b. IV therapy to correct fluid and electrolyte imbalances.
c. an antiemetic, such as pyridoxine, to control nausea and vomiting.
d. enteral nutrition to correct nutritional deficits.
ANS: B
Initially, the woman who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.
A patient who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include: (Select all that apply.)
a. iron supplementation.
b. resumption of intercourse at 6 weeks following the procedure.
c. referral to a support group if necessary.
d. expectation of heavy bleeding for at least 2 weeks.
e. emphasizing the need for rest.
ANS: A, C, E
The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation is also necessary. Acknowledge that the patient has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The patient should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider.
The reported incidence of ectopic pregnancy in the United States has risen steadily over the past two decades. Causes include the increase in STDs accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as: (Select all that apply.)
a. pelvic pain.
b. abdominal pain.
c. unanticipated heavy bleeding.
d. vaginal spotting or light bleeding.
e. missed period.
ANS: A, B, D, E
A missed period or spotting can easily be mistaken by the patient as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the patient often exhibits severe pain accompanied by intra-abdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.
In planning for home care of a woman with preterm labor, which concern must the nurse address?
a. Nursing assessments will be different from those done in the hospital setting.
b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic effects.
d. Home health care providers will be necessary.
ANS: C
Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged after birth recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many women will receive home health nurse visits, but care is individualized for each woman.
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug?
a. Assessing deep tendon reflexes (DTRs)
b. Assessing for chest discomfort and palpitations
c. Assessing for bradycardia
d. Assessing for hypoglycemia
ANS: B
Terbutaline is a 2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. 2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects?
a. Urine output of 160 mL in 4 hours
b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/dL
ANS: D
The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.
A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:
a. stimulate fetal surfactant production.
b. reduce maternal and fetal tachycardia associated with ritodrine administration.
c. suppress uterine contractions.
d. maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
ANS: A
Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?
a. Estriol is not found in maternal saliva.
b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
c. Fetal fibronectin is present in vaginal secretions.
d. The cervix is effacing and dilated to 2 cm.
ANS: D
Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.
A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman’s labor?
a. She is exhibiting hypotonic uterine dysfunction.
b. She is experiencing a normal latent stage.
c. She is exhibiting hypertonic uterine dysfunction.
d. She is experiencing pelvic dystocia.
ANS: C
Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. The contraction pattern seen in this woman signifies hypertonic uterine activity. Typically uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes
Which assessment is least likely to be associated with a breech presentation?
a. Meconium-stained amniotic fluid
b. Fetal heart tones heard at or above the maternal umbilicus
c. Preterm labor and birth
d. Postterm gestation
ANS: D
Postterm gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.
A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?
a. Prolonged latent phase
b. Protracted active phase
c. Arrest of active phase
d. Protracted descent
ANS: C
With an arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
In evaluating the effectiveness of oxytocin induction, the nurse would expect:
a. contractions lasting 80 to 90 seconds, 2 to 3 minutes apart.
b. the intensity of contractions to be at least 110 to 130 mm Hg.
c. labor to progress at least 2 cm/hr dilation.
d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.
ANS: A
The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 80 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min.
A pregnant woman’s amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority?
a. Placing the woman in the knee-chest position.
b. Covering the cord in sterile gauze soaked in saline.
c. Preparing the woman for a cesarean birth.
d. Starting oxygen by face mask.
ANS: A
The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.
Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:
a. enhance uteroplacental perfusion in an aging placenta.
b. increase amniotic fluid volume.
c. ripen the cervix in preparation for labor induction.
d. stimulate the amniotic membranes to rupture.
ANS: C
It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.
The nurse, caring for a patient whose labor is being augmented with oxytocin, recognizes that the oxytocin should be discontinued immediately if there is evidence of:
a. uterine contractions occurring every 8 to 10 minutes.
b. a fetal heart rate (FHR) of 180 with absence of variability.
c. the patient’s needing to void.
d. rupture of the patient’s amniotic membranes.
ANS: B
This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The patient’s needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient’s membranes have ruptured.
Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance:
a. the terms preterm birth and low birth weight can be used interchangeably.
b. preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
c. low birth weight is anything below 3.7 lbs.
d. in the United States early in this century, preterm birth accounted for 18% to 20% of all births.
ANS: B
Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 lbs. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency.
With regard to the care management of preterm labor, nurses should be aware that:
a. all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms.
b. Braxton Hicks contractions often signal the onset of preterm labor.
c. preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver.
d. the diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
ANS: D
Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.
As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
a. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks.
b. there are no important maternal (as opposed to fetal) contraindications.
c. its most important function is to afford the opportunity to administer antenatal glucocorticoids.
d. if the patient develops pulmonary edema while receiving tocolytics, intravenous (IV) fluids should be given.
ANS: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.
With regard to dysfunctional labor, nurses should be aware that:
a. women who are underweight are more at risk.
b. women experiencing precipitous labor are about the only “dysfunctionals” not to be exhausted.
c. hypertonic uterine dysfunction is more common than hypotonic dysfunction.
d. abnormal labor patterns are most common in older women.
ANS: B
Precipitous labor lasts less than 3 hours. Short women more than 30 lbs overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women less than 20 years of age.
The least common cause of long, difficult, or abnormal labor (dystocia) is:
a. midplane contracture of the pelvis.
b. compromised bearing-down efforts as a result of pain medication.
c. disproportion of the pelvis.
d. low-lying placenta.
ANS: C
The least common cause of dystocia is disproportion of the pelvis.
Nurses should be aware that the induction of labor:
a. can be achieved by external and internal version techniques.
b. is also known as a trial of labor (TOL).
c. is almost always done for medical reasons.
d. is rated for viability by a Bishop score.
ANS: D
Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons.
While caring for the patient who requires an induction of labor, the nurse should be cognizant that:
a. ripening the cervix usually results in a decreased success rate for induction.
b. labor sometimes can be induced with balloon catheters or laminaria tents.
c. oxytocin is less expensive than prostaglandins and more effective but creates greater health risks.
d. amniotomy can be used to make the cervix more favorable for labor.
ANS: B
Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe.
With regard to the process of augmentation of labor, the nurse should be aware that it:
a. is part of the active management of labor that is instituted when the labor process is unsatisfactory.
b. relies on more invasive methods when oxytocin and amniotomy have failed.
c. is a modern management term to cover up the negative connotations of forceps-assisted birth.
d. uses vacuum cups.
ANS: A
Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation.
The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births.
a. Viral
b. Periodontal
c. Cervical
d. Urinary tract
ANS: A
The infections that increase the risk of preterm labor and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the patient to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labor and birth. The presence of urinary tract infections increases the risk of preterm labor and birth.
The standard of care for obstetrics dictates that an internal version may be used to manipulate the:
a. fetus from a breech to a cephalic presentation before labor begins.
b. fetus from a transverse lie to a longitudinal lie before cesarean birth.
c. second twin from an oblique lie to a transverse lie before labor begins.
d. second twin from a transverse lie to a breech presentation during vaginal birth.
ANS: D
Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated.
The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is:
a. a gravida 3 who has had two low-segment transverse cesarean births.
b. a gravida 2 who had a low-segment vertical incision for delivery of a 10-lb infant.
c. a gravida 5 who had two vaginal births and two cesarean births.
d. a gravida 4 who has had all cesarean births.
ANS: D
The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture.
Before the physician performs an external version, the nurse should expect an order for a:
a. tocolytic drug.
b. contraction stress test (CST).
c. local anesthetic.
d. Foley catheter.
ANS: A
A tocolytic drug will relax the uterus before and during version, thus making manipulation easier. CST is used to determine the fetal response to stress. A local anesthetic is not used with external version. The bladder should be emptied; however, catheterization is not necessary.
A maternal indication for the use of forceps is:
a. a wide pelvic outlet.
b. maternal exhaustion.
c. a history of rapid deliveries.
d. failure to progress past 0 station.
ANS: B
A mother who is exhausted may be unable to assist with the expulsion of the fetus.
The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum extraction.
The priority nursing intervention after an amniotomy should be to:
a. assess the color of the amniotic fluid.
b. change the patient’s gown.
c. estimate the amount of amniotic fluid.
d. assess the fetal heart rate.
ANS: D
The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Secondary to FHR assessment, amniotic fluid amount, color, odor, and consistency is assessed. Dry clothing is important for patient comfort; however, it is not the top priority.
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
a. measuring urinary output.
b. increasing infusion rate every 30 minutes.
c. monitoring uterine response.
d. evaluating cervical dilation.
ANS: C
Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse’s priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients.
Immediately after the forceps-assisted birth of an infant, the nurse should:
a. assess the infant for signs of trauma.
b. give the infant prophylactic antibiotics.
c. apply a cold pack to the infant’s scalp.
d. measure the circumference of the infant’s head.
ANS: A
The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.
Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction?
a. Amniotomy
b. Intravenous Pitocin
c. Transcervical catheter
d. Vaginal insertion of prostaglandins
ANS: C
Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include hydroscopic dilators such as laminaria tents (made from desiccated seaweed), or Lamicel (contains magnesium sulfate). Amniotomy is a surgical method of augmentation and induction.
Intravenous Pitocin and insertion of prostaglandins are medical methods of induction.
Complications and risks associated with cesarean births include: (Select all that apply.)
a. placental abruption.
b. wound dehiscence.
c. hemorrhage.
d. urinary tract infections.
e. fetal injuries.
ANS: B, C, D, E
Placental abruption and placenta previa are both indications for cesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with delivery by cesarean section.
Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse in the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include: (Select all that apply.)
a. rupture of membranes at or near term.
b. convenience of the woman or her physician.
c. chorioamnionitis (inflammation of the amniotic sac).
d. postterm pregnancy.
e. fetal death.
ANS: A, C, D, E
These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks’ completed gestation.
A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman’s fundus?
a. One centimeter above the umbilicus
b. Two centimeters below the umbilicus
c. Midway between the umbilicus and the symphysis pubis
d. Nonpalpable abdominally
ANS: A
Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth after birth week the fundus normally is halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.
Which woman is most likely to experience strong afterpains?
a. A woman who experienced oligohydramnios
b. A woman who is a gravida 4, para 4-0-0-4
c. A woman who is bottle-feeding her infant
d. A woman whose infant weighed 5 lbs, 3 ounces
ANS: B
Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify.
A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman?
a. Lochia rubra
b. Lochia sangra
c. Lochia alba
d. Lochia serosa
ANS: D
Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.
Which hormone remains elevated in the immediate after birth period of the breastfeeding woman?
a. Estrogen
b. Progesterone
c. Prolactin
d. Human placental lactogen
ANS: C
Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta and reach their lowest levels 1 week into the after birth period. Human placental lactogen levels decrease dramatically after expulsion of the placenta.
Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early after birth period is:
a. elevated temperature caused by after birth infection.
b. increased basal metabolic rate after giving birth.
c. loss of increased blood volume associated with pregnancy.
d. increased venous pressure in the lower extremities.
ANS: C
Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid.
An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.
A woman gave birth to a 7-lb, 3-ounce infant boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate after birth period, the most serious consequence likely to occur from bladder distention is:
a. urinary tract infection.
b. excessive uterine bleeding.
c. a ruptured bladder.
d. bladder wall atony.
ANS: B
Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.
The nurse caring for the after birth woman understands that breast engorgement is caused by:
a. overproduction of colostrum.
b. accumulation of milk in the lactiferous ducts.
c. hyperplasia of mammary tissue.
d. congestion of veins and lymphatics.
ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue.
A woman gave birth to a 7-lb, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman’s vital signs, the nurse would be concerned to see:
a. temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50.
b. temperature 37.4° C, heart rate 88, respirations 36, BP 126/68.
c. temperature 38° C, heart rate 80, respirations 16, BP 110/80.
d. temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.
ANS: A
An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications.
Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?
a. “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.”
b. “My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles.”
c. “I will not have a menstrual cycle for 6 months after childbirth.”
d. “My first menstrual cycle will be heavier than normal and then will be light for several months after.”
ANS: B
“My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles” is an accurate statement and indicates her understanding of her expected menstrual activity. She can expect her first menstrual cycle to be heavier than normal (which occurs by 3 months after childbirth), and the volume of her subsequent cycles will return to prepregnant levels within three or four cycles.
The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the:
a. involutionary period because of what happens to the uterus.
b. lochia period because of the nature of the vaginal discharge.
c. mini-tri period because it lasts only 3 to 6 weeks.
d. puerperium, or fourth trimester of pregnancy.
ANS: D
The puerperium, also called the fourth trimester or the after birth period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy.
The self-destruction of excess hypertrophied tissue in the uterus is called:
a. autolysis.
b. subinvolution.
c. afterpain.
d. diastasis.
ANS: A
Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpain is caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.
With regard to the after birth uterus, nurses should be aware that:
a. at the end of the third stage of labor it weighs approximately 500 g.
b. after 2 weeks after birth it should not be palpable abdominally.
c. after 2 weeks after birth it weighs 100 g.
d. it returns to its original (prepregnancy) size by 6 weeks after birth.
ANS: B
After 2 weeks after birth, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks after birth the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.
With regard to after birth pains, nurses should be aware that these pains are:
a. caused by mild, continuous contractions for the duration of the after birth period.
b. more common in first-time mothers.
c. more noticeable in births in which the uterus was overdistended.
d. alleviated somewhat when the mother breastfeeds.
ANS: C
A large baby or multiple babies overdistend the uterus. The cramping that causes after birth pains arises from periodic, vigorous contractions and relaxations, which persist through the first part of the after birth period. After birth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies after birth pain because it stimulates contractions.
Post birth uterine/vaginal discharge, called lochia:
a. is similar to a light menstrual period for the first 6 to 12 hours.
b. is usually greater after cesarean births.
c. will usually decrease with ambulation and breastfeeding.
d. should smell like normal menstrual flow unless an infection is present.
ANS: D
An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding.
With regard to after birth ovarian function, nurses should be aware that:
a. almost 75% of women who do not breastfeed resume menstruating within a month after birth.
b. ovulation occurs slightly earlier for breastfeeding women.
c. because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium.
d. the first menstrual flow after childbirth usually is heavier than normal.
ANS: D
The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first after birth menstrual period, contraceptive options need to be discussed early in the puerperium.
As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:
a. kidney function returns to normal a few days after birth.
b. diastasis recti abdominis is a common condition that alters the voiding reflex.
c. fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium.
d. with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.
ANS: C
Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.
Knowing that the condition of the new mother’s breasts will be affected by whether she is breastfeeding, nurses should be able to tell their patients all the following statements except:
a. breast tenderness is likely to persist for about a week after the start of lactation.
b. as lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day.
c. in nonlactating mothers colostrum is present for the first few days after childbirth.
d. if suckling is never begun (or is discontinued), lactation ceases within a few days to a week.
ANS: A
Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples.
With regard to the after birth changes and developments in a woman’s cardiovascular system, nurses should be aware that:
a. cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth.
b. respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth.
c. the lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections.
d. a hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.
ANS: B
Respirations should decrease to within the woman’s normal prepregnancy range by 6 to 8 weeks after birth. Stroke volume increases, and cardiac output remains high for a couple of days. However, the heart rate and blood pressure return to normal quickly. Leukocytosis increases 10 to 12 days after childbirth and can obscure the diagnosis of acute infections (false-negative results). The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth.
Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?
a. Varicosities of the legs
b. Carpal tunnel syndrome
c. Periodic numbness and tingling of the fingers
d. Headaches
ANS: D
Headaches in the after birth period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition.
Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?
a. Nail brittleness
b. Darker pigmentation of the areolae and linea nigra
c. Striae gravidarum on the breasts, abdomen, and thighs
d. Spider nevi
ANS: A
The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women spider nevi persist indefinitely.
Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the patient understands the correct process for completing these conditioning exercises when she reports:
a. “I contract my thighs, buttocks, and abdomen.”
b. “I do 10 of these exercises every day.”
c. “I stand while practicing this new exercise routine.”
d. “I pretend that I am trying to stop the flow of urine midstream.”
ANS: D
The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees.
Which maternal event is abnormal in the early after birth period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba
ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.
Which finding 12 hours after birth requires further assessment?
a. The fundus is palpable two fingerbreadths above the umbilicus.
b. The fundus is palpable at the level of the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus.
ANS: A
The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours after birth. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours after birth; however, it is still appropriate.
If the patient’s white blood cell (WBC) count is 25,000/mm on her second after birth day, the nurse should:
a. tell the physician immediately.
b. have the laboratory draw blood for reanalysis.
c. recognize that this is an acceptable range at this point after birth.
d. begin antibiotic therapy immediately.
ANS: C
During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.
Which documentation on a woman’s chart on after birth day 14 indicates a normal involution process?
a. Moderate bright red lochial flow
b. Breasts firm and tender
c. Fundus below the symphysis and not palpable
d. Episiotomy slightly red and puffy
ANS: C
The fundus descends 1 cm/day, so by after birth day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.
Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A after birth nurse anticipates blood loss of: (Select all that apply.)
a. 100 mL.
b. 250 mL or less.
c. 300 to 500 mL.
d. 500 to 1000 mL.
e. 1500 mL or greater.
ANS: C, D
The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). During the first few days after birth the plasma volume decreases further as a result diuresis. Pregnancy-induced hypervolemia (an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth.
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of after birth hemorrhage in this woman is:
a. retained placental fragments.
b. unrepaired vaginal lacerations.
c. uterine atony.
d. puerperal infection.
ANS: C
This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause after birth hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to:
a. begin an intravenous (IV) infusion of Ringer’s lactate solution.
b. assess the woman’s vital signs.
c. call the woman’s primary health care provider.
d. massage the woman’s fundus.
ANS: D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.
A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.
The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?
a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.
ANS: A
This patient’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the patient needs a blood transfusion. Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
a. running warm water on her breasts during a shower.
b. applying ice to the breasts for comfort.
c. expressing small amounts of milk from the breasts to relieve pressure.
d. wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.
A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:
a. “Didn’t you like your lunch?”
b. “Does your doctor know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”
ANS: D
“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.
In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice:
a. is inconsistent with the Baby-Friendly Hospital Initiative.
b. promotes longer periods of breastfeeding.
c. is perceived as supportive to both bottle-feeding and breastfeeding mothers.
d. is associated with earlier cessation of breastfeeding.
ANS: A
Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers.
A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans’ sign and asks what it means. The nurse’s best response is:
a. “You have pitting edema in your ankles.”
b. “You have deep tendon reflexes rated 2+.”
c. “You have calf pain when the nurse flexes your foot.”
d. “You have a ‘fleshy’ odor to your vaginal drainage.”
ANS: C
Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A “fleshy” odor, not a foul odor, is within normal limits.
In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
a. has recovered from epidural or spinal anesthesia.
b. has hidden bleeding underneath her.
c. has regained some flexibility.
d. is a candidate to go home after 6 hours.
ANS: A
If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.
Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.
a. 24, 73
b. 24, 96
c. 48, 96
d. 48, 120
ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
a. the father of the infant.
b. her mother (the infant’s grandmother).
c. her eldest daughter (the infant’s sister).
d. the nurse.
ANS: D
In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.
Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. formally initializing individualized care by confirming the woman’s and infant’s identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
b. teaching the mother to check the identity of any person who comes to remove the baby from the room. (“It’s a dangerous world out there.”)
c. including other family members in the teaching of self-care and child care. (“We’re all in this together.”)
d. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
ANS: D
Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.
Excessive blood loss after childbirth can have several causes; the most common is:
a. vaginal or vulvar hematomas.
b. unrepaired lacerations of the vagina or cervix.
c. failure of the uterine muscle to contract firmly.
d. retained placental fragments.
ANS: C
Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. determine which pad is best.
c. demonstrate that other nurses usually underestimate blood loss.
d. reveal to the nurse supervisor that one of them needs some time off.
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:
a. pouring water from a squeeze bottle over the woman’s perineum.
b. placing oil of peppermint in a bedpan under the woman.
c. asking the physician to prescribe analgesics.
d. inserting a sterile catheter.
ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.
If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?
a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
b. Having the patient flex, extend, and rotate her feet, ankles, and legs.
c. Having the patient sit in a chair.
d. Notifying the physician immediately if a positive Homans’ sign occurs.
ANS: C
Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans’ sign (calf muscle pain or warmth, redness, or tenderness) requires the physician’s immediate attention.
As relates to rubella and Rh issues, nurses should be aware that:
a. breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
b. women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination.
c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
ANS: B
Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination.
Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:
a. at the time of admission to the nurse’s unit.
b. when the infant is presented to the mother at birth.
c. during the first visit with the physician in the unit.
d. when the take-home information packet is given to the couple.
ANS: A
Discharge planning, the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.
A recently delivered mother and her baby are at the clinic for a 6-week after birth checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:
a. discusses her labor and birth experience excessively.
b. believes that her baby is more attractive and clever than any others.
c. has not given the baby a name.
d. has a partner or family members who react very positively about the baby.
ANS: C
If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor, or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The patient may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.
Postpartal overdistention of the bladder and urinary retention can lead to which complications?
a. After birth hemorrhage and eclampsia
b. Fever and increased blood pressure
c. After birth hemorrhage and urinary tract infection
d. Urinary tract infection and uterine rupture
ANS: C
Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to after birth hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.
Rho immune globulin will be ordered after birth if which situation occurs?
a. Mother Rh–, baby Rh+
b. Mother Rh–, baby Rh–
c. Mother Rh+, baby Rh+
d. Mother Rh+, baby Rh–
ANS: A
An Rh– mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh– the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh– blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.
